The Second Sample – Blood Group Checks So You Can Catch Some ZZZZs
Author: Connie Colavecchia, BSc, MLT, Manager, Transfusion Medicine and Tissue Bank, Sunnybrook Health Science Centre
The transfusion of an ABO incompatible red cell is every Blood Banker’s nightmare. Countless studies have identified that “wrong blood in tube” (the blood drawn into the tube does not belong to the patient whose identification label is affixed on the tube), affectionately known as WBIT, has the potential to be a catastrophic event causing morbidity or death. Patient identification processes, supported by standards and industry requirements, are paramount in preventing such events. In early 2018, CSA Z902-15 Blood and Blood Components was revised as follows:
Clause 10.6.1.3 states: To provide ABO group compatible red blood cells, there shall be at least two determinations of the recipient’s blood group on record:
a. One from a current sample and the second from the recipient’s previous records:
b. Testing of a separate sample collection or
c. Retesting of the same sample where positive patient identification technology was used at the time of sample collection.
The original clause referred specifically to electronic crossmatch only. The revised clause applies to all compatibility testing.
Sunnybrook Health Sciences Centre is no stranger to these strategies. In 2004, positive patient identification technology was implemented in two high volume transfusion areas of the hospital, the outpatient transfusion clinic and the inpatient oncology ward. With this technology in place, the risk of a WBIT was virtually zero. However, this technology was not available institution wide. In late 2005, several near miss WBIT events from the Emergency Department (ED) occurred in a short period of time which led to an immediate policy change. Non group O patients from the ED would be provided with group specific blood only if two concordant blood groups were on file. Prior to transfusion, if there was no historical blood group on file, a new group and screen sample was required to confirm the ABO of the first sample. Not in place at the time, CSA Clause 10.6.1.3 b) now provides for this safety check. The intent, although obvious to some, was to ensure that the patient’s group and screen was confirmed on two independent occasions. For some time, this process appeared to be working until the blood bank became aware that the clinical team, in an effort to be efficient, collected two tubes from the same draw and held one back “just in case” the blood bank requested a second sample for the blood group check. This process circumvented the patient safety initiative of confirming that the first group and screen sample and the second group and screen sample had been collected following patient identification checks as per hospital policy on separate occasions. To ensure that the blood group check sample was being collected independently of the first group and screen (Pink top tube), a process was implemented in January 2011 across the institution for all blood groups whereby a special tube, the Royal Blue top tube, available only from the blood bank was accepted as the blood group check. The Royal Blue top tube could not be purchased by anyone else in the institution nor stored anywhere else, only in the blood bank. If a blood group check was required for a patient, the blood bank would request that the Royal Blue tube be retrieved from the blood bank and used only for that specific patient. The process worked well until the blood bank was notified that the Royal Blue top tube was required for a specific test in biochemistry. The resolution was to source another tube to be used only for the blood group check. The Tan top tube was found and replaced the Royal Blue top tube. The blood group check requirement is specific to those patients who may require transfusion and whose only group and screen on record is less than 24 hours old. The 24 hour criteria is in place to discourage the collection of more than one Pink top tube when the first group and screen is collected. A bag containing the Tan top tube is prepared with the patient’s name on the outside of the bag along with instructions (see Figure 1). Following the 24 hours of the first group and screen on record, a Pink top tube is required.
The implementation of the blood group check has decreased the risk of ABO incompatible transfusions and serves as an effective solution until positive patient identification technology is rolled out institution wide. As for me, I sleep better knowing that our institution has taken these added patient safety steps.
The Top Ten Hospital Issues Identified at Annual ORBCoN/CBS Hospital Site Visits from 2018-19
Authors: Sheena Scheuermann MLT BTech, Regional Project Coordinator €; Wendy Owens ART B Comm Program Manager €; Susan White MLT Hospital Liaison Specialist¥, Amanda Nowry MLT BSc Hospital Liaison Specialist¥
€Ontario Regional Blood Coordinating Network, ¥Canadian Blood Services.
Each year, staff from the Ontario Regional Blood Coordinating Network (ORBCoN) and from Canadian Blood Services (CBS) plan site meetings with all hospitals in Ontario to discuss blood utilization. The purpose of these meetings is to:
- Build and maintain relationships
- Encourage continuing improvement in inventory management
- Communicate evidence based best practices in the field of transfusion medicine
- Communicate messages from the Ministry of Health and Long-Term Care (MOHLTC) regarding the provincial Blood Utilization Strategy
- Discuss hospital issues related to transfusion to bring forward to CBS and MOHLTC
Hospital issues are tracked through minutes of the meetings. In 2018-19 we also captured issues through a meeting evaluation survey sent out following the meeting. Issues were analyzed and the ten most common were identified.
Top Ten Hospital Issues as Reported to ORBCoN/CBS during 2018-19:
1. Second sample requirement for ABO group confirmation for patients without historical group on file
This issue was most frequently cited by hospitals this year during our site visits. The logistics of implementing this process was challenging for many hospitals. In January 2018, CSA released a revision to their Z902-15 Standards that introduced the need for a second sample to confirm ABO group for any compatibility testing (was previously only required for computer or electronic crossmatch).1 Several hospitals reported pushback from clinical staff as this requirement for an additional blood draw appeared to be contradictory to policies around minimizing phlebotomy. It is important to note that this standard relates to ABO group only (not Rh) and to red cells only (not other components). More hospitals reported they are considering implementing Positive Patient Identification (PPID) technology for sample procurement which removes the need for a separate sample draw.
2. Lack of engagement by physicians and nurses around hospital transfusion related issues
While many hospitals have been reporting improvements in this, many are still reporting it is a challenge for them. Implementation of policies on managing blood shortages, informed consent, the need for the second sample for group confirmation all involve and require clinical staff to ensure they are implemented. Physician and nurse attendance and participation on Transfusion Committees is also an issue for several sites. Sites also reported there is still some difficulty screening inappropriate orders for products if there is a lack of medical backup.
3. Lack of engagement of Senior Administrators with transfusion related issues within the hospital
Many laboratory professionals report that it is often difficult to raise transfusion related issues with Senior Management and, as a result, they struggle to implement real change. This is a longstanding issue and could possibly be related to the fact that hospital administrators do not have to ‘pay’ for blood. There is some reality to the fact that if you don’t pay for something, it will not receive as much attention, particularly from Senior Administrators who may be primarily concerned about issues that affect the budget of the hospital.
4. Transitioning to new Plasma Protein Products as a result of the new CBS contracts
Hospitals reported several issues that made it challenging to proceed with transitioning patients to the new products. Some of those raised during the site visits were:
- Lack of availability of requested vial sizes
- Backorders of products or product vial sizes
- Storage temperature restrictions for shelf-life, limiting available product and available storage space if refrigerated environment required
- Time and logistics to re-train all patients currently using Sub Cutaneous Immune Globulin (SCIG)
- Concerns around increased risk of reactions moving to a product not currently in use
5. Limitations around transport options in Northern Ontario
Transportation options have always been a challenge in the Northern parts of our province. Generally, there are fewer service providers and distances are longer. Earlier this year, Greyhound Bus announced they were discontinuing service in Northern Ontario west of Sudbury. Many hospitals depended on Greyhound to provide their blood components and products if not for regular delivery, as an alternative to their regular provider. Without access to this option, the ability to request STAT orders or to redistribute products has become more challenging.
6. Platelet related issues
Some reported issues related to platelets include:
- Receiving short dated platelets from CBS – with the introduction of platelets with a 7 day expiry, there may have been a misunderstanding of the expectations for additional shelf-life. In general, the shelf-life gained was approximately 24 hours due to additional testing and ‘holding’ time required to allow for the extension of the expiry date
- Related to the above extension of shelf-life, a reduction in the outdate rate of platelets was seen at many hospitals and overall availability of platelets improved
- Sites that rarely stock platelets need to order in each time a physician requests them. Some physicians may not understand they will likely need to be discarded if the order is changed. This can lead to increased wastage rates. It is important to communicate to CBS, when ordering a platelet in this situation, if there is no order to transfuse. CBS may then be able to issue a platelet with longer remaining shelf-life. This increases the chance to redistribute the platelet if not used which would prevent discarding it due to outdating. Hospitals are encouraged to make use of ORBCoN’s platelet web application to facilitate redistribution https://transfusionontario.org/en/documents/?cat=platelets
7. Scarcity of available Medical Laboratory Technologists (MLTs)
Several small rural hospitals reported they were having difficulty filling available positions and one small site had to shut down temporarily until staffing could be found. As many technologists are retiring or nearing retirement age, there are heightened concerns over looming shortages of certified MLTs. With the increase of core laboratories, it is also difficult for technologists to develop expertise in the field of transfusion. Another challenge related to this issue is that fewer technologists are electing to apply for supervisory or managerial roles. This has left several sites without this much needed position for extended periods of time.
8. Increased workload for MLTs
Two main issues were raised related to an increase in ‘non-measurable or non-billable’ workload for MLTs:
- Implementing prospective screening by technologists as part of the Ontario Transfusion Quality Improvement Plan. Sites that have introduced prospective screening of blood orders to improve the appropriateness of blood components and products ordered by clinicians have noticed an increased workload. There is no argument that it is very time consuming in the beginning when this practice/policy is first introduced. However, many sites that introduced this policy report that their requests for blood have actually decreased which, in the long run, saves technologist time.
- A number of hospitals indicated that Sub-cutaneous Immune Globulin (SCIG) use was increasing and placing an additional workload burden on their departments. Preparing and issuing SCIG is not recognized as measurable laboratory workload, therefore, hospital managers have difficulty in increasing FTE levels to accommodate this. Both CBS and ORBCoN have been asked to advocate on their behalf.
9. Slow transition to Fibrinogen concentrate (FC)
Many sites report they were waiting to hear more evidence to support use of FC for acquired hypofibrinogenemia. With the recent release of the revised statement on fibrinogen from the National Advisory Committee on Blood and Blood Products (NAC)2 perhaps this issue may resolve over the next six to twelve months. Additional information about the efficacy of FC will be available after results from the FIBRES (FIBrinogen REplenishment in Surgery) study are published. As a result of a cryoprecipitate shortage early in 2019, hospitals are being encouraged to put policies and procedures in place to enable them to stock and use fibrinogen concentrate in the event of a similar future shortage of cryoprecipitate.
10. Increased component wastage related to activations of Massive Hemorrhage Protocols (MHP)
A few sites continue to hold an inventory of thawed AB plasma and a large portion of these are not used in an MHP. This was confirmed in an ORBCoN provincial audit of AB plasma completed in 20183. During site visits this past year, ORBCoN and CBS were also told that cryoprecipitate or plasma is often thawed when the protocol is activated but then not used. Improving the definition of when an MHP should be activated could help improve this issue. For sites that do not have a high number of MHP activations, it may be more prudent to thaw and prepare plasma and/or cryoprecipitate upon activation or when the product is requested. Use of fibrinogen concentrate for massively bleeding patients may also prevent wastage of cryoprecipitate.Platelets may also be pre-emptively ordered in but then not be required. Platelets are generally issued in a later ‘pack’ or ‘box’. Many sites expressed interest in the work that is being done on the development of a provincial MHP and are looking forward to the release of the recommendations as well as the toolkit.
Platelets may also be pre-emptively ordered in but then not be required. Platelets are generally issued in a later ‘pack’ or ‘box’. Many sites expressed interest in the work that is being done on the development of a provincial MHP and are looking forward to the release of the recommendations as well as the toolkit.
- Canadian Standards Association. CSA Z902-15 Standards on Blood and Blood Components. October 2015. rev Jan 2018.
- National Advisory Committee on Blood and Blood Products. NAC Statement on Fibrinogen Concentrate. July 2018.
- Ontario Regional Blood Coordinating Network. transfusionontario.org. [Online].; Ontario 2018 AB Plasma Audit Report [cited 2019 April]. Available from: http://www.transfusionontario.org.
ORBCoN’s patient pamphlet is now a one-pager designed for patients and families to provide basic information on blood transfusion and to help patients make informed decisions regarding their treatment options. This resource was pared down in size and volume to focus on key messages important to patients and health professionals. In conjunction with the revised one-pager, ORBCoN developed a Questions to Ask Your Doctor sheet as a tool for patients to prepare for their visits with clinicians.
Previously the Blood Transfusion: Information for Patients short version was a hard copy booklet that was ordered online. This resource is no longer available to order. The new version and the Questions to Ask Your Doctor sheet are easily accessible for download on our website at www.transfusionontario.org under the tab “For Patients” → “Patient Booklets”. The options for download are:
- Blood Transfusion: Information for Patients, v3 Short Version PDF, and
- Customizable Blood Transfusion: Information for Patients, v3 Short Version PDF with option to insert your hospital/site logo, and
- Questions to Ask My Doctor PDF.
Please note that Blood Transfusion: Information for Patients, v2 Long Version will remain available and supported online at www.transfusionontario.org under the “For Patients” tab to provide additional information for those patients who are looking for a more detailed resource.
Provincial Redistribution Check-Up
Authors: Tracy Cameron MLT and Sheena Scheuermann MLT, BTech, Regional Project Coordinators, Ontario Regional Blood Coordinating Network
December 2018 marked the first anniversary of the launch of the revised Provincial Redistribution Program for Transfusion Services in Ontario Toolkit. The process for redistributing blood components and products was evaluated by a provincial working group in 2016 and the toolkit was revised with standardized procedures to ensure that the security and safety of the redistributed blood components and products are maintained during shipment. The process was validated to demonstrate that acceptable temperatures and traceability will be maintained when redistributing or transferring blood components or products between facilities within Ontario.
The program relies on 3 types of shipping containers. Hospitals can choose which container to use based on the blood component/product being shipped. The first type is the J82 container, the old Canadian Blood Services (CBS) shipping container which can be used to ship any products that need to be maintained between 1 and 10°C during shipment. The second container type is the E38 container, which again is the old CBS shipping container to ship any products that need to be maintained between 20 to 24°C during shipment. The third is the Pelican Biothermal Series 4 shipping container (formally known as MTS EMT or Golden Hour box) which is used to ship any products that need to be maintained between 1 and 10°C during shipment. The difference between the 3 shipping containers is the packing material used to maintain the required temperatures.
Each of these shipping containers have been validated using criteria defined by ORBCoN and in consultation with transfusion medicine service staff. The table below shows the validation results for each of the shipping containers using the established packing configuration to maintain the required acceptable shipping temperatures. If hospitals choose to use a different configuration for the shipping containers, then they must do their own validation and need to share their validation with any sites that they would ship product to if requested as part of the provincial redistribution program.
Hospitals are requested to indicate their agreement to participate in the provincial redistribution program by completing a memorandum of understanding (MOU) which states the hospital will follow a standardized process, use a validated packing configuration and acknowledge how they are pre-conditioning ice packs used in the J82 packing configuration. Once hospitals have submitted this MOU it is then stored on file at ORBCoN and can be provided to any hospital that receives components or products from that shipping hospital. This reassures the receiving sites that the products or components they are receiving have been stored, packed and shipped appropriately and can be accepted into their inventory for patient use. A list of all hospitals who have submitted their MOU can be found on ORBCoN’s Transfusion Ontario website here.
To aid in compliance with IQMH requirements (IQMH v 7.1 APR 2017: IV.2 TM 070) ORBCoN, along with participating hospitals, will perform ongoing temperature verifications on the shipping containers. Sites may be approached to help perform these verifications by adding data loggers (supplied by ORBCoN) to one of their redistribution shipments. The sites will follow the standard packing configurations and add the data loggers in the placement identified in the Standard Operating Procedure (SOP) provided. After the shipment is complete, the sites will send the data loggers back to ORBCoN with the supplied shipping labels. The results of these ongoing verifications are posted on transfusionontario.org. ORBCoN looks forward to working with hospitals to ensure the ongoing temperature verification of these boxes and thanks those who have already assisted.
The redistribution program allows hospitals to send near to expiring components and products to other sites where they may be utilized before they expire. Hospital efforts to ensure that blood components and products provided by Canadian donors are not wasted are shown in the graph below.